Nokea
A mother brings her 8-month-old baby boy to the clinic because he has been vomiting and having diarrhea for the last 3 days. Which assessment is most important for the nurse to make?
- A. Assess the infant's abdomen for tenderness
- B. Determine if the infant has been exposed to a virus
- C. Measure the infant's pulse
- D. Evaluate the infant's cry
Correct Answer: C
Rationale: The most crucial assessment in this scenario is to measure the infant's pulse. Pulse measurement is essential to evaluate the severity of dehydration, which can be a significant concern in a baby experiencing vomiting and diarrhea for several days. Assessing the abdomen for tenderness may provide information on potential causes of symptoms but is not as urgent as monitoring hydration status. Determining exposure to a virus is important for infection control but does not directly address the immediate issue of dehydration. Evaluating the infant's cry, although a form of communication, does not provide critical information regarding the baby's physiological status in this situation.
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The healthcare provider is caring for a 6-year-old child diagnosed with glomerulonephritis. Which finding should the healthcare provider report promptly to the healthcare provider?
- A. Dark-colored urine
- B. Mild periorbital edema
- C. Blood pressure of 150/95 mm Hg
- D. Urine output of 250 mL in 24 hours
Correct Answer: C
Rationale: Hypertension is a serious complication of glomerulonephritis, as it can lead to further renal damage. A blood pressure reading of 150/95 mm Hg is elevated and should be reported promptly to the healthcare provider for immediate management to prevent complications. Dark-colored urine can be a common symptom of glomerulonephritis due to blood in the urine but is not as urgent as managing hypertension. Mild periorbital edema can also be seen in glomerulonephritis but is not as concerning as elevated blood pressure. Urine output of 250 mL in 24 hours indicates oliguria, which is a concern, but addressing hypertension takes priority to prevent further renal damage.
A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea (sudden aimless movements of the arms and legs). Which information should the nurse provide to the parents?
- A. Permanent lifestyle changes need to be made to promote safety in the home
- B. The chorea or movements are temporary and will eventually disappear
- C. Muscle tension is decreased with fine motor project skills, so these activities should be encouraged
- D. Consistent discipline is needed to help the child control the movements
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What recommendation should the PN provide to help a 5-year-old girl who has started wetting the bed again after being dry at night for several months?
- A. Explain that bedwetting is normal in children and will pass with time.
- B. Advise limiting fluids in the evening and before bedtime.
- C. Suggest punishing the child for wetting the bed to prevent recurrence.
- D. Encourage the child to use the bathroom immediately before bed.
Correct Answer: D
Rationale: Encouraging the child to use the bathroom before bed is a helpful recommendation to prevent nighttime bedwetting. Bedwetting can sometimes reoccur due to stress or other factors, and ensuring the child empties their bladder before sleeping may reduce the likelihood of bedwetting episodes. Choice A is incorrect because while bedwetting is common in children, it is essential to provide practical solutions rather than just reassurance. Choice B is not the best option for a child who has recently started bedwetting again after being dry, as it may not address the underlying cause. Choice C is inappropriate and harmful as punishing the child for bedwetting can lead to psychological distress and worsen the situation.
During a follow-up clinical visit, a mother tells the nurse that her 5-month-old son, who had surgical correction for tetralogy of Fallot, has rapid breathing, often takes a long time to eat, and requires frequent rest periods. The infant is not crying while being held, and his growth is in the expected range. Which intervention should the nurse implement?
- A. Stimulate the infant to cry to produce cyanosis
- B. Auscultate the heart and lungs while holding the infant
- C. Evaluate the infant for failure to thrive
- D. Obtain a 12-lead electrocardiogram
Correct Answer: B
Rationale: Auscultating the heart and lungs while the infant is held is the most appropriate intervention to assess his current condition. This action allows the nurse to gather important information regarding the cardiovascular and respiratory status of the infant, which is crucial in evaluating his post-surgical recovery and overall well-being. Option A is incorrect as stimulating the infant to cry intentionally is not necessary and could cause distress. Option C is incorrect as the infant's growth is within the expected range, indicating no signs of failure to thrive. Option D is incorrect as obtaining a 12-lead electrocardiogram is not the initial intervention needed in this situation; assessing the heart and lungs through auscultation is more immediate and informative.
The mother of a 9-month-old, diagnosed with respiratory syncytial virus (RSV) yesterday, calls the clinic to inquire if it will be all right to take her infant to the first birthday party of a friend's child the following day. What response should the nurse provide this mother?
- A. The child will no longer be contagious, so no need to take any further precautions.
- B. Ensure there are no children under the age of 6 months around the infected child.
- C. The child can be around other children but should wear a mask at all times.
- D. Do not expose other children to RSV. It is highly contagious even without direct contact.
Correct Answer: D
Rationale: The correct answer is D. RSV is highly contagious, even without direct contact. It is important to prevent the spread of the virus to other children, so the infected child should not attend the birthday party to avoid exposing other children to RSV. This is crucial to protect the health of other children who may be more vulnerable to the virus. Choices A, B, and C are incorrect. Choice A is incorrect as RSV remains contagious for a period of time, and precautions should be taken to prevent its spread. Choice B is incorrect because the age limit specified is not a reliable measure to prevent transmission. Choice C is incorrect as wearing a mask may not be sufficient to prevent the spread of RSV in a social setting like a birthday party.